LEVERAGING WEB-BASED MODULAR

TECHNOLOGIES TO ENHANCE MEANINGFUL USE OF EHRs

Jatinder R. Palta, PhD, Professor and Chief of Physics,

Department of Radiation Oncology

University ofFlorida Shands Cancer Center, Gainesville, FL

IHE-ROTask Force Co-Chair

Martin Pellinat, CEO

VisionTree Software

September 9, 2010

Topics for Discussion

• Applying new modular health information technology to current

workflow to measure outcomes in cancer patients in an academic

medical center

• The use of modular technologies in other Meaningful Use data sets

• Discuss the perceive and documented benefits and physician adoption

rates associated with patient-centered data collection and

communication

• Coordinating care team responses with meaningful analysis of

outcomes data

Radiotherapy Workflow / Process Overview

• Multidisciplinary review

– Radiation oncologists, medical oncologists, surgeons,

pathologists, radiologists review imaging, lab reports, and

medical history

• Patient immobilization and imaging for radiation treatment planning

• Treatment target and normal tissue delineation

• Treatment planning

• Patient setup for treatment and plan verification

• Radiation treatment

• On treatment review

• Post treatment follow-up

LiteBox

MAGN

ETOM

LiteBox

TPS

RT-EMR

CT

CT SIM

LINAC

Simplified Radiotherapy Process

Detailed Radiotherapy Process

MAGNETOM

MAGNETOM

LiteBox LiteBox

LiteBox

LiteBox

CT MR

DB

Archive

HIS/EMR

Portal Imaging

Virtual SIM. TPS LinacReview

Station

Simulator

Image

SS, Plan,

Dose,Image

Image AllNon

DICOM Image

Record

PlanMulti Image

SS, Plan,

Multi Image

Typical RT dataset/patient includes DICOM Images, Plan, and Dose

(300 M byte - 4 G byte)

SS, Plan,

Dose,

Multi Image

Radiation Oncology Patient Portal: Key Use Case

The Radiation Oncology Patient Portal (ROPP) provides a patient with authenticated and authorized access to a

set of patient specific reports and alerts for Meaningful Use as required by the ARRA HITECH Act.

Patient Portal Attributes:

• Secure Patient Login - patient can login to the portal from a computer outside the enterprise.

• PRO Completion - Patients can complete QoL assessments in their secure portal. Assessments can be

delivered at specified time points (i.e. pre-treatment, 3 month, 6 month, 12 month, etc).

• Reminders & Messaging – triggers set by the provider will send email/SMS text alerts and reminders to the

patient and medical team

• Registration / Health History - Patients can provide registration and health history information.

An integrated EHR and integrated Medical Team & Patient Portal system enables:

• Pharmacy, Lab Results, Procedure Eligibility - data access.

• Treatment Summary and Relevant Education Materials - meeting ARRA requirements.

• Clinical Trials - Visibility of appropriate ongoing clinical trials, clinical trial matching.

• Connectivity to remote/home monitoring systems.

• Reminders, messages and forms - triggered based on data values.

• Data analysis and trends – on medical team side, patient-level reporting.

Radiation Oncology Patient Portal: Use Cases /

Meaningful Use Criteria

* Highlighted Measures represent those that can benefit from connectivity with or use of a ROPP.

**ARRA HITECH Act Meaningful Use Core and Menu Measures can be found at: http://healthit.hhs.gov.

ARRA HITECH: Act Core Measure (15 Must Be Met)* ROPP

1. Record Patient Demographics X

2. Record Vital Signs & Chart Changes

3. Maintain Up-To-Date Problem List & Active Diagnosis

4. Maintain Active Medication List X

5. Maintain Active Allergy Medication List X

6. Record smoking status for patients 13+ yrs old X

7. Provide Clinical Summary / Hosp. Discharge Instructions X

8. On Request, Provide ePHR X

9. Generate & Transmit ePrescriptions

10. Computer Provided Order Entry (CPOE) for Medications

11. Implement Drug/Allergy Interaction Check X

12. Implement Prov./Pt. Exchange of Clinical Information X

13. Implement & Track One Clinical Decision Support Rule

14. Implement System to Protect Privacy & Security of PHI X

15. Report Clinical Quality Measures to CMS / State

ARRA HITECH: Act Menu Measure (7 of 12 Must Be Met)* ROPP

1. Implement Drug Formulary Check

2. Incorporate Lab Results in Structure Data Format X

3. List Patients by Condition for Quality Improvement,

Research

4. Identify Patient-Specific Resources and Provide to Patients X

5. Perform Medication Reconciliation Between Care Settings X

6. Provide Summary of Care Record for Patients Referred X

7. Submit Electronic Immunization Data to Registries

8. Submit eSyndromic Surveillance Data to Public Health

Agencies

9. For Hospitals Record Advance Directives

10. For Hospitals, Submit eLab Data to Public Health

Registries

11. Send Reminders to Patients for Preventive/

Follow-Up Care

X

12. Provide Patients with Timely ePHR Access X

Patient Portal / Interoperability for

Collecting & Aggregating Outcomes Data

Query/RetrieveData element “X”

Patient Portal(HRQoL)

Data element “”

Clinician Portal(CRO)

Data element“”

RT-EMR(MOSAIQ, ARIA...)

Data elements independently validated by clinical team

EHR / PHR(Health Vault, Google Health...)

RT-PACS

URL Redirect

X

X

XXX

XX

X

XXXXX X X X

X

X X

X X X

X

X

X

XXX

X

XX

X

XXXX

PQI(PAAROT)

National Radiation Oncology Registry (NROR)*(Disease Site-specific CRO and PRO Data Elements for Each Patient)

Web-based Data Entry / Reporting Template

OCER

PQRI(Compliance and Quality Reports)

*Courtesy IEEE Computer

Society; August, 2010; Palta,

Frouhar, Zlotecki

ROPP can facilitate the development of a

National Radiation Oncology Registry (NROR).

ROPP use case will allow abstraction of NROR

data elements from RT_EMR, patent/ clinician

portal and generation of quality reports. ROPP

use case is an essential step to achieve

“Meaningful Use” of RT-EMR.

Layered Patient Portals in Care Continuum

Layered Patient Portals

( Temporal)

Pre-treatment Patient Portal(Education material, facility info., Intake data forms, medical record posting

On-treatment Patient Portal(Appointments, Medications, Medical test results, Alerts & reminders, Adverse reaction reporting, etc.)

Post-treatment Patient Portal(HRQoL instruments for longitudinal studies, Toxicity reporting; Rule and Role-based communication and feedback)

*Courtesy IEEE Computer

Society; August, 2010; Palta,

Frouhar, Zlotecki

Patient-level data may be exchanged between

patient, provided coordinated care team

and PHR (e.g. HealthVault, Google Health)

Radiation Oncology Patient Portal

facilitates longitudinal collection of PRO

data (HRQoL data)

Radiotherapy Data Abstraction for

Outcome Studies and EHR

Query/RetrieveData element “X”

Patient Portal(HRQoL)

Data element “”

Clinician Portal(CRO)

Data element“”

RT-EMR(MOSAIQ, ARIA...)

Data elements independently validated by clinical team

EHR / PHR(Health Vault, Google Health...)

RT-PACS

URL Redirect

X

X

XXX

XX

X

XXXXX X X X

X

X X

X X X

X

X

X

XXX

X

XX

X

XXXX

PQI(PAAROT)

RT Data profile(Disease Site-specific CRO and PRO Data Elements for Each Patient)

Web-based Data Entry / Reporting Template

OCER

PQRI(Compliance and Quality Reports)

*Courtesy IEEE Computer

Society; August, 2010; Palta,

Frouhar, Zlotecki

MAGNETOM

NetSysImages

DICOM

DICOM-RT

RTOG

•Visualize (2D 3D), DVH, Iso-dose, Cutplane, etc.

•Case info

•Review

•Modify Structures

•Annotate

•Etc.

RCET

Server

Web Based

Upload/Download Tool

Clinic PC

RCET

Database

NetSys

DICOM-RT

Server

NetSys

RTOG

Reader

NetSys

Image

Reader

Web Based Electronic

Folder & Rapid Review

Tools

Imaging Device

Treatment Planning

Film Scanner

SOANS

External

Database

Reviewer PC

NetSys

(1)

(3) (2)

RCET Infrastructure

Palta:04/06/0512

Performs Auto Archiving of Submitted Case Data

Allows Fast Multi User Internet Access

Data Authoring and Versioning (DAV) control keeps track of authors and changes to the data

The database is designed to overcome network bandwidth limitations and allow future growth

Palta:04/06/0513

This component is best understood in analogy with Picture Archiving Computerized Systems (PACS)

The SOANS deals with any data object encountered in radiation therapy

The SOANS is protocol centric in data organization

The SOANS supports secure encrypted data transfer across a wide area network (WAN)

The SOANS provides the interface between the database and the client applications

The SOANS can be queried for data objects based on any of their database attributes (similar to PACS)

Palta:04/06/0514

Allows Preparation and Submission of Radiotherapy and Diagnostic Imaging Data

DICOM Server and Image Interpreter imports

Performs Anonymization of Patient Data

Views Are Set for Rapid Web Review

A thick client application

Palta:04/06/0515

Allows review of Data Prepared with the NetSys PC Client: JPEG snapshots of the originals Viewing of CT, MR, Port Film, DRR, DVH, scanned images, and Radiotherapy PlanAccessible Seconds After SubmissionSecure WAN Multi User Access A thin client application

16

Rapid Image Viewer

• Displays

diagnostic

and

treatment

verification

images

• Images are

organized in

an electronic

folder

Patient Portal Data Interchange

Standards & Systems

Radiation

Oncologist Portal

Patient Portal

PAAROT MOC

National Quality

Benchmark

Clinical Research

Portal

Tumor

Registry

RO Database

HISP Servers

HTTPS

HTTPS

HTTPSDICOM-RT

Push

HL-7 Push

Enterprise Info

System (EIS)

Client Tier (Browser or Application)

Web

Tie

r

Bu

sin

ess T

ier

Hosp

ita

l EIS

In

terf

ace

RT-PACS

RT-EMR

HIS

HL7

In/Outbound

HL7

In/Outbound

CCR / CCD

PHR Data

Interchange

Monitoring

Systems

(Hypertension,

Glucose) w/ API

Open ID / Oauth

Single Sign-On

HTTPS

• Data exchange and reporting to data registries to meet

ARRA HITECH Act Stage 1 and forthcoming Stage 2 & 3

Requirements.

ROPP: Roles & Quality Alerts

Based on a user‟s role (i.e. physician, researcher, nurse, or other medical team member will

be able to:

• Patient Account & Consent Management - create, access, update, send/receive

messages.

• Update Patient Portal Data - schedule modifications, medications / refills based on patient

request.

• Set patient specific alerts

• Read / Respond to patient specific alerts

• Send / Receive Quality Alerts - triggered by roles, metrics, tasks and form completion &

outcomes data collection, toxicity grades, lab results & related adverse events and

messaging are necessary for quality care and treatment.

• Generate Quality Metrics Reports - including identifying QA performed on behalf of

patient, e.g. IMRT QA or lack thereof and real-time national quality benchmark data.

Radiation Oncology &

Coordinated Care Team

Patient Workflow

1) Patient logs on to their secure,

web portal.

2) Completes CCR, outcomes

assessments and forms at

specific time points.

3) Receives reminders for forms

completion, appointments.

4) Secure 2-way messaging for

appt / refill requests & needs.

5) Ability to view/store labs, imaging.

6) Receive Treatment Summary

(CCR/CCD) and Treatment

Pathway follow-up reminders /

educational material.

Patient Portal Features & Data Exchange

Data Cascades Between EMR / VTOC Forms

Roles & Rules-Based Alerts

Set / Send Alerts & Triggers from Discreet Form Data

Radiation Oncology Clinical /

Disease Specific Templates

Includes Form Sharing Library &

Best Practice Templates

Data „cascades‟ between

EMR and VTOC portal system for

form for auto-completion and

reporting, including:

• VTOC forms data from

Registration, H&P, Toxicity

QoL forms

• Roles-based forms

completion.

• Rules-based notification

Data Cascades Between EMR / VTOC Forms

Scheduled Data Export to EMR

• Mapping / Crosswalk of VTOC forms & files

• Auto-export to EMR via HL7 message w/ Document Type

Radiation Oncology Quality Reporting

by Disease Type

EMR Connectivity for Aggregate Quality Measures Dashboard with

National Benchmark Data &Reporting/Filters on a Department Level

Patient-Level & Aggregate Reporting

• Patient Lists by Diagnosis / Self-Generated Reporting Queries for Clinical & QoL data.

• Demographic, Procedure & Diagnosis Data Filters w/ Excel® export.

• 5,000+ Patients - with OTV and long-term QoL data including: IPSS, EPIC, IIEF

• 1,000+ patients actively using patient portal

o 80% online participation

o 90%+ want to keep using it long-term

o Average age: 60+ yrs old

• VTOC Cancer Center sites nationally include:

o UF Shands / UFPTI

o UPENN

o ProCure Treatment Centers

o Henry Ford

o UCSF

o UCLA / Athena Breast Cancer Registry

o ASTRO PAAROT National MOC Quality Reporting Program

• Other Results Include:

o 6 Peer Reviewed Abstracts

o 30% post-treatment quality of life

o 30% missed canceled

o RTOG 0828 (20 Sites) Measuring: Form Completion/Quality, Patient Compliance & Alerts

UF Shands & UFPTI

VTOC Results & Other Experiences

• Clinical Team / Patient Paperless Workflow

- Registration, H&P, PROs, eCRFs, CCR/CCD

delivered to patient for Treatment Summary

• Alerting & Reporting

- Layer on top of EMR & Practice Management Systems for

collecting QoL and toxicity data sent via email/SMS text

as actionable triggers

• Integration

- Data Extraction & Mapping

- HL7, XML, CSV Connectivity

• Web & Mobile Access

- Providers, Patients, Registry Admin

• Messaging, Compliance & Education

- Clinical templates deliver and collect information

• Large Scale Data Capture & Analytics

- Community connectivity

Patient Portal

for Meaningful Use

PRO/QoLs, OTV, H&P,

CCR/CCD

Treatment Summary

Quality, A/E Alerts,

Msg, Case Conferencing

Reporting, Real-Time Metrics

ROPP: Overarching Data Exchange

* Courtesy of Office of the National Coordinator for HIT (ONC): http://healthit.hhs.gov

NHIN Direct: Point-to-Point Patient-Level Data Exchange Model That may be used for the ROPP